In our on-demand era of reproductive liberty and technology, a child’s sex isn’t always left up to chance. As more parents have the option of choosing the sex of their baby before getting pregnant, they’re walking headfirst into an ethical quandary of what this means for their family and the prospective baby. But as any parent who has ever projected a desire onto a future child—which is, sadly, nearly all of us—what does it mean when we want a child of a specific sex, and what if they fail to meet that gender-stereotyped standard?

The United States and Western Europe are not facing the staggering sex-imbalance of China and India, but opting for one sex over another still has consequences, says Ruth Macklin, professor emerita at Albert Einstein College of Medicine and author of The Ethics of Sex Selection and Family Balancing.

The most obvious unexpected outcome is that parents who want a boy to do masculine things, like playing football, or a girl to do feminine things, like ballet or wearing dresses, may get a child who prefers none of these things, or a child who doesn’t identify with the sex they’re born into.

The ethics on sex selection vary depending on the methods that parents choose. At the extreme end is the sex-selective abortion, which has contributed to the dramatic sex-imbalance in Asian countries that value boys even as more regions outlaw the practice. In the gray area is the preimplantation genetic screening, when a couple undergoes IVF and screens the embryos, then elects to implant a specific sex. While numbers are not published about the parents who undergo IVF specifically for sex selection, 2016 set yet another record for babies born by IVF: over 70,000. Preimplantation genetic screening can be covered by insurance in some states and under certain conditions. But as more parents screen for hereditary diseases and carrier genes, like Huntington’s or the breast cancer genetic mutation BRCA, the global preimplantation genetic testing market is expected to reach over $500 million by 2022.

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“If you look at the evolution of ASRM (Association Society for Reproductive Medicine) guidelines, it’s the best descriptor of how the conversation around this issue has changed,” said Lauren Flicker, associate director of the Montefiore Einstein Center for Bioethics, who advises reproductive health clinicians on the ethics surrounding sex-selection practices. In their first Ethics Committee Report on sex-selection, in 1999, the ASRM said it “presents ethical problems,” unless undertaken for a specific medical reason. In 2001, ASRM updated the report to make sex-selection ethically permissible for “family balancing”—i.e., parents of sons seeking a daughter. But family balancing was also a flawed ethical argument, one that Macklin described as “arbitrary.” ASRM’s current ethical guidelines say sex-selection decisions are up to individual providers of fertility treatments.

Judith Daar, chair of ASRM’s Ethics Committee, estimates that 90 percent of clinics now offer non-medical sex selection, a number that’s grown in the past five years. The Centers for Disease Control estimates that 5 percent of assisted reproductive technology cycles in the U.S. include preimplantation genetic testing, though Daar acknowledges that sex selection is considered an attractive offer for some parents, which could continue to nudge the numbers higher.

Also growing in popularity are “gender-swaying” options like the Babydust Method, which depend on timing and frequency of intercourse preceded by months of precise ovulation tracking to produce a boy or a girl. Medical experts dismiss this as unproven, but Kathryn Taylor, the creator of Babydust, based her method on a scientific study that relied on cervical mucus ovulation testing instead of the Luteinizing Hormone strips that Babydust recommends (and sells). Taylor boasts a 94 percent success record and a rapidly-growing Facebook group of over 17,000 members.

Danielle Dubasak had her son through IVF. The clinic declined to perform pre-implantation genetic screening for sex, and selected the “largest healthiest looking embryo,” said Dubasak, a teacher at Baltimore City Schools, who is still hoping for a girl. She’s charting her ovulation cycle and trying the Babydust method at home. If her second child “is another amazing baby boy,” she says she’ll look into transferring the eight remaining frozen embryos to another clinic to screen for a girl, which she estimates costs $300 to $500 to transfer, and another $3,000 for the screening, which does not include any of the costs of IVF. Dubasak has heard rumors that her clinic—a well-known East Coast establishment—might be changing their policies on sex screening, as many clinics have already done. “That would make it a lot easier for me!” she said.

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However, a spokesperson for Shady Grove Fertility confirmed that while they do offer sex-selection if a patient undergoing IVF requests it, they do “not offer IVF to otherwise fertile individuals solely for the purposes of selecting the sex of their children.”

Michelle Cromwell, an ICU nurse who lives in the Houston suburbs, was devastated when she learned her baby girl wasn’t going to survive in utero, and was delivered at 20 weeks. She and her husband went on to have three boys, including one via intrauterine insemination using sperm sorting, a technique with a 70 to 80 percent success rate for choosing the sex. But Cromwell still mourns her lost daughter and has visions of raising a girl of her own. “My boys are my world, and I could never ever replace them, but that doesn’t change the void I still have in my heart. It isn’t about replacing my daughter, it’s about wanting to raise a daughter.” She and her husband are researching IVF options and a clinic that will allow screening for sex; they’ve decided to only implant if female embryos are produced.

Expecting a child of one sex and winding up with another, the parents might be more at risk of “gender-disappointment”; grief surrounding the “loss” of the desired son or daughter.

Macklin, Daar, and Flicker see no ethical quandaries in trying such at-home methods as Babydust without a clinician involved nor any invasive procedures. Though in expecting a child of one sex and winding up with another, the parents might be more at risk of “gender-disappointment”; grief surrounding the “loss” of the desired son or daughter.

“That grief can look a lot like depression,” said Rachel Freedman, a Washington-area psychologist focusing on maternal mental health. “It’s a loss for that particular person. A lot of times people have built up in their minds a picture of what their family is going to look like.”

Psychologists interviewed for this article have noticed an increase in gender disappointment: parents, typically moms, typically wanting girls, mourning that the child they’re having is not the one they’d expected. (Taylor, too, says the most common request in Babydust is moms wanting a daughter, and Americans appear to want daughters more than they want sons, according to Gallup polling.)

But even the name “gender-disappointment” is misleading, explains Julie Bindeman, a licensed psychologist and co-director of Integrative Therapy of Greater Washington. “If it’s a child, you’re talking about ‘genitalia disappointment.’ We can’t determine gender on an ultrasound.” Bindeman attributes some of that rise in gender disappointment to the early chromosomal detection tests that let parents know the child’s sex before the first trimester ends, and the way our society values baby girls.

“It’s interesting in utero and infancy we treat and value girls very differently than older girls, adolescents and young women in that culture,” said Bindeman. “There is this value of this preciousness of a baby girl. We can see that in the clothes, the lacy, delicate ones, not meant to get dirty. But think about how we treat women: Women are undervalued in paid work and unpaid work.”

There are valid reasons for wanting daughters other than hair bows and expectations. There is evidence that the maternal grandparents are the ones given hands-on access to the grandchildren, while the dad’s parents are instructed to tread lightly, lest they interfere with their daughter-in-law. In a country facing striking Medicaid cuts and little in the way of long-term care for the elderly, there’s evidence that “the best long-term care insurance in our country is a conscientious daughter” as daughters are 28 percent more likely to care for aging parents than sons. A researcher who studied parents with only one child found that with few exceptions, it was moms that wanted girls and dads that wanted boys.

But there are reasons to want a boy that doesn’t stem from visions of a baseball uniform or other arbitrary masculine standards, too. Fathers were more likely to stay married to mothers of boys, according to a study of Census data, with wide-ranging speculative reasons why, including the father wanting to be a role model for their biological son, and mothers of daughters being more willing to leave a bad marriage. When Taylor was crafting her Babydust Method, she opted to plan for a boy first for myriad reasons, among them her hope that having a son would increase her husband’s ability to bond with the baby. (She’s since had two more daughters—both planned according to her Babydust steps.)

There may be racial underpinnings to this sex-preference conversation, too. Although there is no data on the racial breakdown of sex-selection, anecdotally it’s not uncommon for African-American families to worry about the racism and physical danger Black boys face in the U.S., a fear that might contribute to a preference for girls.

But is there anything wrong with someone wanting something—for any reason, be it the perceived idea of sharing Laura Ingalls Wilder books with a daughter that a son would be less interested in, or a father coaching a tee ball game for his son, that a daughter might be less inclined to participate? All of these, of course, are based on gender stereotypes and parents projecting their own ideas of what a parent-child relationship could look like with their offspring. There will be girls on tee-ball teams and boys reading about Laura and Mary, and there are plenty of gender-neutral activities, books, and pastimes that a parent can channel their projections toward instead. But the simple act of longing for that relationship isn’t at fault here. Parents will always project desires onto children, it’s channelling those desires into productive courses when things wind up not as planned (the child who doesn’t want to play sports, the girl who won’t wear smocked dresses, the boy who identifies as a girl, the mom who wants a daughter but only has sons), this deviation is where our true parenting skills lie, in both accepting our child for who they are and finding a way to cultivate a relationship within that context.

Because, as any parent can attest: There will be things in child-raising that do not go according to plan. And discovering those unexpected outcomes is part of what makes child-rearing fascinating.

“People do things in the hopes of having a certain type of child all the time, they enroll their child in ballet or sports even though she hates it, and has no aptitude. They choose a partner with certain traits so their child will have those traits. We do this consciously and subconsciously all the time,” said Flicker. “Is it discomfiting? Possibly. Is it unethical? I don’t see it.”

But experts believe that the focus on sex only has larger ramifications. “As individuals and as a society, we haven’t thought very carefully about what it means for the child in your family to have their sex so desired that you will spend a lot of money and effort to get that sex,” says Marcy Darnovsky, the executive director for the Center for Genetics and Society. Darnovsky acknowledges there is a growing cultural interest in determining the sex of a child that raises some of the same issues. “Why is it so important to control the sex of the child?”

Darnovsky believes the United States does have a role to play in the global obsession with sex selection. She spoke of an international public health specialist who approached her at a conference abroad, begging her to persuade American feminists to speak out about the aggressive sex-selection procedures in India that were terminating pregnancies of baby girls. Although Americans hoping for a specific sex may be leaning the opposite direction, the obsession with sex-selection may still be an issue. “Is what we’re doing really unrelated?” Darnovsky asked. “It doesn’t feel unrelated to me.”

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About the Author

Rebecca Gale is an award-winning journalist with years of experience covering the nexus of politics and people in Washington, D.C. Her work has appeared in The Washington Post, Slate, Marie Claire, Cosmopolitan, and Health Affairs, among other outlets.